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Understanding borderline personality disorder

Borderline personality disorder (BPD) is a controversial diagnosis, but some useful work has been done in recent years to discover the best ways to help people with this condition.

This booklet aims to explain what the diagnosis means, and for those who are given this diagnosis, what can and should happen next. It suggests sources of help for people diagnosed with BPD, their friends and relatives.

What is borderline personality disorder?
What if I disagree with the diagnosis?
What are the typical feelings and experiences of people with BPD?
How common is BPD?
What causes BPD?
What helps people with BPD?
Which talking treatments can help people with BPD?
What other therapies can help?
Can drugs help with BPD?
Where can I find further help?
How can family and friends help?
How can I help myself?
Can I recover from BPD?
References
Useful organisations
Useful websites
Further reading

For me having borderline personality disorder is having constant and unremitting feelings of unbearable and overwhelming sadness, anger, depression, negativity, hatred, emptiness, frustration, helplessness, passivity, procrastination, loneliness and boredom. Feelings of anxiety are like silent screams in my head and it is as if masses of electricity are channelling through my body.

NICE BPD guidelines

What is borderline personality disorder?

BPD is one of many personality disorders listed in the diagnostic manuals used by clinicians when they are giving someone a psychiatric diagnosis.

Below are the symptoms of borderline personality disorder according to recent government guidelines (National Institute for Health and Clinical Excellence [NICE] 2009). A doctor will diagnose borderline personality disorder in persons who have five or more of these symptoms and if the symptoms have a significant impact on them.

having emotions that are up and down (for example, feeling confident one day and feeling despair another), with feelings of emptiness and often anger
difficulty in making and maintaining relationships
having an unstable sense of identity, such as thinking differently about yourself depending on who you are with
taking risks or doing things without thinking about the consequences
harming yourself or thinking about harming yourself (for example, cutting yourself or overdosing)
fearing being abandoned or rejected or being alone
sometimes believing in things that are not real or true (called delusions) or seeing or hearing things that are not really there (called hallucinations).

Note: People with borderline personality disorder have high rates of other mental health related problems, such as depression, anxiety, eating disorders and substance misuse (drugs or alcohol).

The question of 'personality disorders' is controversial, as what some experts term as 'personality' others regard as 'the self'; so any suggestion that a person's self is disordered, damaged or flawed can be distressing. It's worth remembering that aspects of almost any type of personality can be found within the pages of the diagnostic manuals. What matters is that you get the help you feel you need. If after reading this booklet you feel you may have BPD, talk to someone who is medically qualified – be very wary of making a self-diagnosis.

What if I disagree with the diagnosis?

Some people feel they are only given this diagnosis because they did not fit easily into any other category. Within the NHS, you are entitled to ask for a second opinion, although this doesn't necessarily mean that your request will be granted. If you feel your GP or psychiatrist has misunderstood you, and you are having problems getting the help you need, you may find an advocate useful. (For more information about advocates, contact the Mindinfoline or see the Mind guide to advocacy.)

What are the typical feelings and experiences of people with BPD?

Some people with BPD may find themselves having a series of unstable and intense relationships, or clinging too long to damaging relationships, perhaps because of feeling insecure, alone or lacking self-worth.

People with BPD may find social relationships difficult because of their poor self image, feelings that they don't fit or don't belong, and moods and feelings which change rapidly. A feeling common to many people with BPD is a deep sense of emptiness. Here is how one person described it:

Feeling bereft and lifeless – with a void I can't fill no matter how much food I put down or activity, exercise, self harm and constant thinking I've gone through. I try to keep busy to combat the emptiness but it only masks it. The best antidote is to try to experience life and relationships more fully then store the better memories.

Some people are tempted to harm themselves when their emotions become intensely painful and hard to cope with or express.

Many of those with BPD will sometimes feel suicidal and may attempt suicide.

When it was really bad, I would be in so much emotional pain that suicide seemed like the only way I could find any release. My attempts at overdosing kept failing: I was secretly screaming for someone to just listen to me and show me a way out. But in the end, if they wouldn't or couldn't be bothered to help me I would rather have been dead than carry on as I was – I just didn't care about anything, apart from getting rid of the pain.

Research shows that people with BPD are more likely to have suicidal thoughts and make suicide attempts compared to people with other psychiatric diagnoses. If this applies to you, or someone close to you, it is important to know where to turn to for help. (See 'Useful organisations' and 'Finding help in a crisis...'.)

How common is BPD?

BPD is thought to affect less than one per cent of the general population. It's been estimated that three-quarters of those given this diagnosis are women. It's a condition that isn't usually diagnosed until adulthood.

What causes BPD?

The causes of BPD are unclear. Most researchers think that BPD develops through interacting factors, such as temperament, childhood and adolescent experiences. Difficult life events such as the early loss of a parent, childhood neglect, sexual or physical abuse are common in people diagnosed with BPD, though this is not always the case, and people with other diagnoses may also have survived this kind of trauma.

In addition, the problems associated with BPD may become much worse following a stressful experience; for example, after the break-up of a relationship or the loss of a job.

What helps people with BPD?

People with BPD have a strong need to feel accepted, heard and understood.
They need a sense of safety; for instance consistent people and places where they can become attached while working through their difficulties.
There are a growing number of talking therapies that may help, when a person is ready and able.
Medication has helped some people to cope with difficult thoughts and feelings.
People with BPD may need a swift response when in crisis, whether it is in the day or at night.
Specialist NHS services can be accessed via the Community Mental Health Team, some in collaboration with social services, and some run by voluntary or independent organisations.

Which talking treatments can help people with BPD?

Brief psychological interventions

Brief psychological interventions are those usually given for less than six months and usually no more frequently than once a week. NICE guidelines do not recommend very brief interventions (less than three months) for people with BPD.

Cognitive behavioural therapy (CBT) is a structured psychological treatment that aims to tackle everyday difficulties through problem-solving techniques, replacing negative thinking patterns with positive ones. CBT has been modified for BPD: it is usually focused on the present, but when used for BPD it takes account of previous experiences which have influenced a person's fundamental beliefs. (See Mind's booklet Making sense of cognitive behaviour therapy.)

Problem-solving therapy (PST) is a brief psychological treatment for depression, based on cognitive-behavioural techniques. It can be used to help people in a crisis after an episode of self harm or attempted suicide. Like CBT, PST focuses on the present and has five stages: adopting a problem-solving strategy; defining the problem and selecting goals; thinking of possible solutions; choosing the best solution; trying it out and looking at the effects.

Manual-assisted cognitive therapy (MACT) is a brief, problem-focused therapy, intended for people who self harm. A manual is used to structure the treatment sessions and to act as a reminder between sessions. The manual covers exploration of the self-harm attempt, crisis skills, problem solving, and how to manage self-harming episodes. It offers up to five sessions within three months of an episode of self-harm, with the option of a further two booster sessions within six months.

Interpersonal therapy (IPT) is a structured, time-limited, supportive therapy which was developed to treat outpatients with major depression. The therapist pays attention to four main areas: sensitivity in relationships with others, managing different social roles and changes of role, disputes with other people and losses. It has been further developed to treat people with BPD.

Cognitive analytic therapy (CAT) combines CBT's practical methods with more attention to the relationship between the therapist and client as a means of examining how relationship patterns might have developed in unhelpful ways, including how the client relates to his or her self. It is particularly designed to deal with damage to the self resulting from long-term experiences of trauma and deprivation.

Individual psychological therapies

These therapies can be brief or longer term. They are usually offered weekly, but sometimes twice-weekly, in an outpatient setting.

Psychodynamic psychotherapy adapted for BPD
Psychotherapists help people become aware of unconscious conflicts which can make them confused and anxious. The relationship between the client and therapist often provides examples of relationship problems and these are discussed. For people with BPD the therapist provides more structure and is more active than usual. There is no set limit to the length of time this type of therapy can take.

Counselling Some forms of counselling are similar to psychotherapy: psychodynamic counselling, for example, places great emphasis on childhood experience. Counselling is often less intensive or lengthy than psychotherapy. (See Making sense of counselling.)

Psychological therapy programmes

Psychological therapy programmes combine more than one treatment; for example, individual therapy plus group therapy.

Dialectical behaviour therapy (DBT) is a mixed method of treatment, initially developed for women who self harm, but is now given to people with BPD. It aims to help people gain more control over their actions and behaviour. Programmes last up to a year, with both individual and group therapy, aiming to reduce suicidal behaviours, self-harm, substance misuse and binge-eating. DBT encourages the person to define their life goals and work towards these. (See Mind's online factsheet Dialectical behaviour therapy.)

Mentalization-based therapy (MBT) teaches greater awareness of how thoughts can have an impact on actions, and how to separate them to give more choice about how to act in any given situation. Mentalization-based therapy and partial hospitalisation is based on the belief that early problems stopped the person from learning how to understand their own and others' mental states. The treatment takes up to 18 months and usually happens in a day hospital. It includes individual and group therapy.

If you are interested in pursuing a talking treatment, you could talk to your GP about seeing someone through the NHS, or getting treatment subsidised; alternatively, if you can afford it, there are private treatments available. (See 'Useful organisations.')

When I received my diagnosis it seemed like there would be no hope for me. It took a few tries, with the help of my doctor, to work out what would be the best kind of treatments for me, but we eventually found something right. Now I'm back in a full-time job, have better relationships with my friends and family and am thinking about buying my own place to live.

What other therapies can help?

Therapeutic communities
A therapeutic community is a 'planned environment' that uses mostly social and group therapies, including: analytic groups, psychodrama, art therapy, cognitive therapy and problem solving. 'Members' of the community encourage each other to discuss their interpersonal and emotional issues and provide feedback to each other to help members develop their awareness of how they interact with other people.

Therapeutic communities for personality disorder range from residential hospitals to units that operate for a few hours on one day each week. Therapeutic communities generally offer time-limited placements. The NHS runs some inpatient therapeutic communities that specialise in treating clients with personality disorders. (See 'Useful organisations'.)

Arts therapies
Arts therapies are sometimes offered to people with BPD. They include art, dance movement, drama and music therapies. These therapies can help people who find it hard to put their thoughts and feelings into words. Therapy is normally undertaken weekly, in small groups or individually. (See Mind's online factsheet Arts therapies.)

Complementary and alternative therapies
Some people find therapies such as massage, reflexology, aromatherapy and healing useful as part of their coping strategies. Some can be accessed through the voluntary sector – check out your nearest local Mind association for any services they may offer.

Can drugs help with BPD?

There are no psychiatric drugs specifically for BPD, but some medications can help to reduce particular BPD symptoms including anxiety, depression, anger and impulsive behaviour.

Antidepressants
These may be prescribed if you are depressed as well as having BPD (see Mind's booklet Making sense of antidepressants).

Anticonvulsants and lithium
These may be prescribed if you have mood disturbances or are diagnosed with a mood disorder as well as BPD (see Making sense of lithium and other mood stabilisers).

Antipsychotics
Antipsychotics (also called major tranquillisers) are sometimes prescribed for people experiencing delusions, hallucinations or rapid thoughts. These drugs can cause weight gain and other unwanted effects. NICE recommend that they are only given short term for people with BPD. (For more information, see Making sense of antipsychotics.)

Where can I find further help?

The starting point

Begin by visiting your GP. If he or she thinks you have BPD, you should be offered an appointment with your local Community Mental Health Team. Their role is to assess your needs and develop a care plan with you, which could include some of the therapies or treatments described in this booklet. They will also look at what support you may need to cope.

Finding help in a crisis or emergency

At times of great distress, you may feel you need to go to a place of safety or feel concerned about the safety of someone you care for who has BPD. If you (or the person you care for) have previously used services, you/they may already have a care plan and a contact person to call. Otherwise you can:

make an emergency appointment with your doctor or call your doctor's surgery out-of-hours service if the emergency is at night or the weekend
call your mental health worker or care co-ordinator if you have one
call your local mental health crisis team (see below)
go to the accident and emergency department at your local hospital
call 999.

Mental health crisis team
Most areas have a mental health crisis team; contact details are through your local council. They are available 24 hours a day, seven days a week and will:

respond to a crisis within four hours wherever possible
carry out assessments under the Mental Health Act 1983
provide support and short-term help until another team is available or the help is no longer needed.

If you need help in a crisis and are assessed as a danger to yourself or to others you may be admitted compulsorily under the Mental Health Act. The Mind rights guides explain your rights with regards to mental health law (see 'Further reading')

What I needed was human contact and reassurance. Once I got to talk to someone on the crisis team and they put in place a follow-up meeting, I immediately felt that I would be able to cope better and not let my ever-changing emotions get out of control. I just wanted some understanding and to know someone cared.

Crisis houses
In some areas there are crisis houses which may be run by social services or voluntary organisations and are free to those offered a place. They usually take referrals from other services or allow people to refer themselves. Crisis houses do not admit people who are subject to the Mental Health Act.

A crisis house may have day services and beds for limited stays, plus various types of therapy and support, practical help with welfare benefits, housing issues, and training in life skills and problem solving. They link closely with other local services.

There may also be an out-of-hours telephone helpline. See Mind's online factsheet Crisis services for more information.

How can family and friends help?

People with BPD can have very low self-esteem, and it can help if you remind them of good things about themselves.
A person with BPD is likely to feel emotionally unstable, so it helps if you can keep stable. You may need to find more support for yourself.
Your loved one may have more than average changes of mood and attitude, and feelings of being abandoned or let down by you. Try not to take this personally.
Try to keep in mind that the person you care about wants very much to be loved and cared for but may not know how to ask for help.
If the person you care about is not receiving any help or therapy then you could help them find information about therapies that might work for them.
You cannot give someone else a sense of self-worth. People with BPD have to find their own way to this, through therapy and hard work. But you can support and encourage them as they go through this process, which is likely to take time.
Learn as much as you can about the disorder and find out whether there are any groups to support families and friends, as well as the person with BPD.

How can I help myself?

There are many things that people with BPD can do to help themselves cope better. Here are a few things people have found helpful:

Get involved in a physical activity such as walking, cleaning, dancing, anything that can distract you from your present emotions.
Play music that creates a very different feeling to the one you are struggling with, e.g. happy music if you are feeling sad, relaxing music if you are anxious.
Phone someone. Just talking to someone you trust can be a big help when you are struggling with strong feelings. Call a supportive friend or family member or a helpline.
Spirituality. Prayer or meditation might help if you are religious or spiritual, and is worth trying even if you are not. Take some quiet time in peaceful surroundings or read something uplifting.
Acknowledge your emotions. Notice the emotion you are having, and let yourself experience it as a wave, without trying to block it, suppress it, or hold on to it. Try to accept the emotion for what it is.
Ride it out. Strong emotional reactions (and the urges to self harm, binge or drink) usually last for a few minutes and then begin to subside. Set a timer for 10 minutes and practice riding out the emotion.
Breathe deeply. Sit or lie somewhere quiet and bring your attention to your breathing. Breathe evenly, slowly, and deeply, letting your stomach rise and fall with each breath.
Have a warm bath or shower. Add some scented bath salts or candles and allow the warm water and pleasant fragrances take you into a different emotional space.
Grounding exercises. Sounds, sights, smells and sensations can help you come back into the present, for instance: take a deep breath, and then start to mentally list the things you see around you; listen to the sounds you hear around you, how they rise and fall and change; take hold of an ice cube and hold it in your hand until it starts to cause mild discomfort; or snap a rubber band against your wrist.
Help someone else. This can be as small a thing as smiling at the shop assistant at the supermarket checkout.

Can I recover from BPD?

There is evidence that BPD symptoms may get better over time, with or without treatment. Research suggests that the majority of people diagnosed with BPD improve in the long term (10 to 15 years), with 50 to 75 per cent no longer showing enough symptoms to meet the criteria for the diagnosis.

I no longer consider myself to have a diagnosis of borderline personality disorder. I have none of the symptoms and when I look around at other people I don't seem to be any different from anyone else. The only time I feel different is when I recognise that my journey to this point in my life has been a lot more complicated than many people I come into contact with. However, when I look around I also see myself handling situations more competently than many other people. I have gained in strength and resilience as a result of my experience of handling such intense emotions.

NICE 2009

Remember that recovery may not be about getting rid of all symptoms and that people can learn to manage their condition better, gain control and aspire to a life worth living.

To regain control we can learn to live alongside our illnesses by re-thinking the way we think, to retrain the way we go about our daily lives and to learn to use our past experiences to guide us to where we want to be in life rather than carrying on the way we do.

The Haven Project, Colchester

References

Castillo, H. (2003) Personality disorder: Temperament or Trauma. Jessica Kingsley Publishers.
Chapman, AL. and Gratz, KL. (2007) The Borderline Personality Disorder Survival Guide. Oakland, CA: New Harbinger
Elliott, C.H. and Smith, L.L. (2009) Borderline Personality Disorder for Dummies, Wiley.
Fonagy, P. and Bateman, A. (2006). "Progress in the treatment of borderline personality disorder." The British Journal of Psychiatry 188(1): 1-3.
Friedel, R. (2004) Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD. New York, Marlowe and Company
The Haven Project, Colchester www.thehavenproject.org.uk
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. The Guilford Press.
NICE (2009) Borderline Personality Disorder – The NICE guideline on treatment and management. NICE
NICE (2009) Borderline personality disorder (BPD): quick reference guide to the NICE Guidelines NICE
Winston, A. (2000). "Recent developments in borderline personality disorder." Advances in Psychiatric Treatment 6(3): 211-217.
Whewell, D and Bonanno, P. (2000) “The care programme approach and risk assessment of borderline personality disorder” Psychiatric Bulletin 24, 381-384.

Useful organisations

Association of Therapeutic Communities
tel. 01242 620 077 web: www.therapeuticcommunities.org
Produces a directory of therapeutic communities

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484 web: www.babcp.com
To find CBT practitioners. Online directory can be searched by specialism e.g. 'personality disorders'

British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300, web: www.bacp.co.uk
For practitioners in your area

The Cassel
tel. 020 8483 2900 web: www.wlmht.nhs.uk
Inpatient therapeutic community (part of West London Mental Health NHS Trust). Click 'services' and then 'C' on the website

NAPAC (National Association for People Abused in Childhood)
infoline: 0800 085 3330 web: www.napac.org.uk
Support, advice and guidance for adult survivors of any form of childhood abuse – sexual, physical or emotional

TalktoFrank
tel. 0800 776 600 web: www.ndh.org.uk
Free 24-hour national drugs helpline

NHS Direct
tel. 0845 46 47 web: www.nhsdirect.nhs.uk
They can advise you on local services for people with personality disorders and courses of action

Samaritans
Chris PO Box 9090, Sterling FK8 2SA
helpline: 08457 90 90 90 web: www.samaritans.org
A 24-hour emergency helpline

UK Council for Psychotherapy (UKCP)
tel. 020 7014 9955 web: www.psychotherapy.org.uk
Has a directory of accredited psychotherapists

Useful websites

www.acat.me.uk
Association for Cognitive Analytical Therapy

http://apt.rcpsych.org/cgi/content/full/8/1/10
Advances in Psychiatric Treatment (Information about Dialectical Behaviour Therapy)

www.bpdworld.org
Information, advice and support to people with BPD, their families, friends and carers

www.emergenceplus.org.uk
A merger between Borderline UK and Personality Plus – forums, information and training

www.mentalising.com

www.nice.org.uk
An independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health

www.personalitydisorder.org.uk